Expert consensus on indocyanine green fluorescence imaging for thoracoscopic lung resection (The Version 2022).

The use of the white-light thoracoscopy is hampered by the low contrast between oncologic margins and surrounding normal parenchyma. As a result, many patients with in situ or micro-infiltrating adenocarcinoma have to undergo lobectomy due to a lack of tactile and visual feedback in the resection of solitary pulmonary nodules. Near-infrared (NIR) guided indocyanine green (ICG) fluorescence imaging technique has been widely investigated due to its unique capability in addressing the current challenges; however, there is no special consensus on the evidence and recommendations for its preoperative and intraoperative applications. This manuscript will describe the development process of a consensus on ICG fluorescence-guided thoracoscopic resection of pulmonary lesions and make recommendations that can be applied in a greater number of centers. Specifically, an expert panel of thoracic surgeons and radiographers was formed. Based on the quality of evidence and strength of recommendations, the consensus was developed in conjunction with the Chinese Guidelines on Video-assisted Thoracoscopy, and the National Comprehensive Cancer Network (NCCN) guidelines on the management of pulmonary lesions. Each of the statements was discussed and agreed upon with a unanimous consensus amongst the panel. A total of 6 consensus statements were developed. Fluorescence-guided thoracoscopy has unique advantages in the visualization of pulmonary nodules, and recognition and resection of the anterior plane of the pulmonary segment. The expert panel agrees that fluorescence-guided thoracoscopic surgery has the potential to become a routine operation for the treatment of pulmonary lesions.

Diagnostic value and safety of medical thoracoscopy under local anesthesia for unexplained diffuse interstitial lung disease: A retrospective study.

OBJECTIVE: We aimed to explore the safety and diagnostic value of medical thoracoscopic lung biopsy in patients with unexplained diffuse interstitial lung disease (ILD) in a single center pilot study. METHOD: We retrospectively analyzed clinical and pathological diagnostic data from 52 patients with diffuse ILD undergoing medical thoracoscopic lung biopsy. RESULTS: Forty-four cases of diffuse ILD were confirmed pathologically, giving a diagnostic rate of 84.6%. Among these 44 patients, 11 patients were diagnosed with cancer, including eight patients with lung adenocarcinoma, three patients with metastases; two from a gastrointestinal malignancy, and one from a granulosa cell tumor of the ovary. There were 17 cases of idiopathic interstitial pneumonia, including nine cases of usual interstitial pneumonia (UIP), four cases of non-specific interstitial pneumonia (NSIP), three cases of cryptogenic organizing pneumonia (COP), and one case of acute interstitial pneumonia (AIP). There were 12 cases of rare interstitial pneumonias, which included six cases of pulmonary alveolar proteinosis, one case each of pulmonary Langerhans cell histiocytosis (LCH) and pulmonary lymphangiomyomatosis, two cases of nodular sarcoidosis, and two cases of chronic eosinophilic pneumonia. We recorded various complications, including bleeding, infection, and pneumothorax. A total of 28 patients (53.8%) experienced at least one of the above complications, but there were no deaths associated with biopsy. CONCLUSIONS: Medical thoracoscopic lung biopsy appears a safe and effective method for diagnosing diffuse ILD of unknown cause but further prospective studies, with larger numbers, including comparison with other established techniques are required.

Efficacy, safety, and optimal timing of single-trocar video-assisted flexible thoracoscopic debridement under local anesthesia for complicated parapneumonic empyema.

OBJECTIVE: Thoracoscopic debridement under local anesthesia is a useful approach for complicated parapneumonic effusion or empyema (CPE) and is a less invasive procedure than video-assisted thoracoscopic surgery under general anesthesia. There are various methods of thoracoscopic debridement under local anesthesia, although the optimal timing of treatment is unknown. The objective of this study was to verify the efficacy and safety of our video-assisted flexible thoracoscopic debridement (VAFTS-D) procedure under local anesthesia, and to investigate the clinical features associated with the success of VAFTS-D. METHODS: The study included 71 consecutive patients with CPE who underwent VAFTS-D. The primary outcome was success of VAFTS-D. We retrospectively analyzed the efficacy and safety of VAFTS-D from the clinical data obtained from hospital medical records, and used univariate logistic analyses to identify potential predictors of the outcome. RESULTS: VAFTS-D was considered successful in 62 of 71 patients (87.3%). Two of the remaining nine patients died and the other seven patients required subsequent operation under general anesthesia. Complications due to VAFTS-D occurred in six patients (8.5%). Duration of empyema < 10 days (P = 0.024) and negative bacterial culture in pleural effusion (P = 0.029) were independently associated with the success of VAFTS-D by univariate logistic regression analysis. CONCLUSION: VAFTS-D might be an acceptable first-line procedure in patients with suspected CPE. VAFTS-D should be performed as early as possible for a successful outcome, and to obtain useful information on the pleural cavity.

Resección por videotoracoscopía de nódulos pulmonares marcados con lipiodol: experiencia en dos centros universitarios / Videotoracoscopy resection of pulmonary nodules marked with lipiodol: experience in two university centers

INTRODUCCIÓN: Para facilitar la localización intraoperatoria de los nódulos pulmonares existe la alternativa de marcarlos previamente con lipiodol. OBJETIVO: Describir los resultados quirúrgicos de los pacientes sometidos a resección por videotoracoscopía de nódulos pulmonares marcados previamente con lipiodol. MATERIAL Y MÉTODOS: Estudio descriptivo. Se incluyeron los pacientes que fueron sometidos a resección por videotoracoscopía de nódulos pulmonares marcados con lipiodol, en Clínica Las Condes e Instituto Nacional del Tórax, entre junio de 2012 y junio de 2019. Se consideraron variables demográficas, radiológicas, quirúrgicas e histológicas. RESULTADOS: Se estudió un total de 93 pacientes. La edad promedio fue 63,5 (± 11,9) años. El tamaño promedio de los nódulos fue de 10,7 (± 5,8) mm. Se identificó y extrajo el 100% de los nódulos marcados. Los días de hospitalización promedio fueron 4,7 (± 6,9). Solo se registró un fallecimiento de causa no quirúrgica. CONCLUSIONES: La resección videotoracoscópica de nódulos pulmonares marcados previamente con lipiodol, es una técnica segura y eficaz.

BACKGROUND: To facilitate the intraoperative location of lung nodules there is the alternative of pre-marking them with lipiodol. OBJECTIVE: To describe the surgical results of patients undergoing videotoracoscopy resection of pulmonary nodules previously marked with lipiodol. MATERIAL AND METHODS: Descriptive study. Patients who underwent videotorcoscopy resection of pulmonary nodules marked with lipiodol were included at Clínica Las Condes and Instituto Nacional del Tórax between June 2012 and June 2019. Demographic, radiological, surgical and histological variables were considered. RESULTS: A total of 93 patients were studied. The average age was 63,5 (± 11.9) years. The average size of the nodules was 10.7 (± 5.8) mm. 100% of the marked nodules were identified and extracted. The average hospitalization days were 4.7 (± 6.9). Only one death of non-surgical cause was recorded. CONCLUSIONS: Videotoracoscopic resection of pulmonary nodules previously marked with lipiodol is a safe and effective technique.

Clinical utility of thoracoscopy in elderly tuberculous pleurisy patients under local anesthesia.

INTRODUCTION: Diagnosing tuberculous pleurisy is important in Japan because it currently has a moderate tuberculosis prevalence. However, physicians often have difficulty making a diagnosis. It was reported that thoracoscopy under local anesthesia is useful for the diagnosis of tuberculous pleurisy, but there are no reports focusing on elderly patients. METHODS: In this study, the usefulness of thoracoscopy under local anesthesia was evaluated in elderly patients. Among 170 patients who underwent thoracoscopy under local anesthesia at our hospital during 11 years from January 2008 to December 2018, those aged 75 years or older (n = 75) were investigated retrospectively. RESULTS: A total of 55 patients underwent thoracoscopy under local anesthesia for detailed examination of pleural effusion of unknown cause. Of these, 18 were diagnosed as tuberculous pleurisy. The median age was 82 years (range: 75-92 years). The diagnosis of tuberculous pleurisy was made in 11 patients in whom Mycobacterium tuberculosis was detected and in four patients whose pathological findings indicated epithelioid granuloma accompanied by caseous necrosis. Clinical diagnosis was made in the remaining three patients based on thoracoscopic findings of the pleural cavity and a high level of adenosine deaminase in pleural fluid. No serious complications attributable to the examination were observed in any patient. CONCLUSIONS: Thoracoscopy under local anesthesia was useful for the diagnosis of tuberculous pleurisy in elderly patients, with useful information being also obtained for the treatment of tuberculosis.

Local Anesthesia Thoracoscopy with versus without Midazolam: A Randomized Controlled Trial.

BACKGROUND: Medical thoracoscopy is the gold standard for the diagnosis of pleural diseases. To date, no consensus exists regarding the choice of sedative and analgesic agents in patients undergoing local anesthetic thoracoscopy (LAT), and questions are raised as to whether sedatives may add to respiratory side effects. OBJECTIVE: The aim of the study was to test the hypothesis that administration of midazolam associated with lidocaine versus lidocaine alone in patients with LAT adds to respiratory side effects. METHODS: We randomly assigned 80 patients to a 1:1 study to 2 groups: local anesthesia by lidocaine (n = 40) versus lidocaine and midazolam (n = 40), with the primary end point being the mean lowest oxygen saturation. The secondary end points were cardiovascular parameters, complications, days of drainage, hospital stay, and patients' quality of life (QoL) as assessed by a visual analog scale (VAS). RESULTS: The mean age of all patients was 66.6 ± 13.1 years. The study comprised 50 males (62.5%). No difference was observed in the demographics between the 2 groups. No significant difference was observed between the 2 groups in oxygen saturation (primary end point). A significant difference was observed in favor of the midazolam group regarding the QoL assessed by VAS. CONCLUSION: Midazolam does not add to respiratory side effects when it is used with lidocaine for LAT, while patients' QoL is actually improved in this group. Therefore, in our department, we changed our startegy in favor of the association of lidocaine and midazolam.

Appropriate amounts proportions of lidocaine gel, indigo carmine and lipiodol mixture for preoperative marking in video-assisted thoracic surgery.

Preoperative marking is necessary in thoracoscopic wedge resections of lung nodules expected to be invisible or nonpalpable during surgery. Recently, lidocaine gel was added to a dye solution containing indigo carmine and lipiodol to promote micelle formation, but the optimal mixing ratio was not determined. Thus, an in vitro experiment was performed to identify the optimal mixing ratio of lidocaine gel, indigo carmine and lipiodol. To fixed volumes of indigo carmine and lipiodol of 0.5 ml each, 0.1, 0.2, 0.3, 0.4 and 0.5 ml of lidocaine gel was added. Changes were examined every 2 h. No changes were seen in the mixtures containing 0.1 and 0.2 ml of lidocaine gel, whereas those with 0.3, 0.4 and 0.5 ml had clearly separated after 2 h. Our findings suggest that the ideal proportion of indigo carmine, lipiodol and lidocaine gel for use in preoperative marking is 5:5:2.

[Advances in the Study of the Effects of Video-assisted Thoracoscopic Segmentectomy 
on Pulmonary Function].

The National Comprehensive Cancer Network (NCCN) clinical practice guideline of non-small cell lung cancer (NSCLC) in 2018 points out that anatomic pulmonary resection is a preferred option for early stage NSCLC. With the development of video-assisted thoracoscopy, minimally invasive thoracic surgery represented by thoracoscopy has been widely used in clinical practice. Video-assisted thoracoscopic segmentectomy has become one of the treatment options for early stage NSCLC. Clinical studies have found that sublobar resection can achieve similar results and preserve more pulmonary function in the treatment of early stage NSCLC compared with lobectomy, but the changes of pulmonary function after segmentectomy are still controversial. This article focuses on the research progress of pulmonary function changes in NSCLC patients after video-assisted thoracoscopic segmentectomy.
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Advances in the Study of the Effects of Video-assisted Thoracoscopic Segmentectomy on Pulmonary Function / 中国肺癌杂志

The National Comprehensive Cancer Network (NCCN) clinical practice guideline of non-small cell lung cancer (NSCLC) in 2018 points out that anatomic pulmonary resection is a preferred option for early stage NSCLC. With the development of video-assisted thoracoscopy, minimally invasive thoracic surgery represented by thoracoscopy has been widely used in clinical practice. Video-assisted thoracoscopic segmentectomy has become one of the treatment options for early stage NSCLC. Clinical studies have found that sublobar resection can achieve similar results and preserve more pulmonary function in the treatment of early stage NSCLC compared with lobectomy, but the changes of pulmonary function after segmentectomy are still controversial. This article focuses on the research progress of pulmonary function changes in NSCLC patients after video-assisted thoracoscopic segmentectomy.
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Local Anaesthetic (Medical) Thoracoscopy Services in the UK.

BACKGROUND: Local anaesthetic thoracoscopy (LAT) is an important procedure in the management pathway of patients with pleural effusions, particularly those with suspected malignancy. The last survey evaluating the use and development of LAT services in the UK was conducted over a decade ago. OBJECTIVES: We performed a survey of LAT practices in the UK to explore procedural preferences and variations in practice. METHODS: The online survey was cascaded via regional pleural specialists to sites performing LAT. One response per site was accepted. RESULTS: Thirty-seven responses were received from England, Scotland and Wales. Most centres have regular access to a dedicated list and a designated area to perform LAT. 97% of the centres have at least 2 trained thoracoscopists. Some variation in practice is seen with patient preparation pre-procedure and medication use. Other procedures, such as insertion of indwelling pleural catheters and adhesiolysis, are not uncommon to be undertaken at the time of LAT. CONCLUSIONS: Overall, the results are comparable, excepting some minor variations in patient preparation pre-procedure. We hope that this survey functions as an information resource for centres developing a LAT service or for those considering expansion.

[Efficacy and safety of argon plasma coagulation plus medical adhesive via thoracoscopy in the treatment of spontaneous pneumothorax with subpleural blebs].

Objective: To evaluate the preliminary efficacy and safety of argon plasma coagulation (APC) plus medical adhesive via thoracoscopy in the treatment of spontaneous pneumothorax caused by subpleural blebs. Methods: Data of totally 51 patients of spontaneous pneumothorax with subpleural blebs treated in Pneumology Department of Rizhao Hospital of Traditional Chinese Medicine from July 2015 to July 2017 were retrospectively analyzed. Among the 51 patients, 59 target bullae were found, 1.2 per patient on average, with the diameter ranging from 0.5 to 5 cm and an average diameter of 2.6 cm. A total of 21 patients were treated with APC, and the rest 30 were treated with APC plus partially sprayed medical adhesive (APC+ group). The rate of air leakage discontinuance within 24 hours after operation, the rate of air leakage discontinuance within one week after operation, the disappearance rate of target subpleural blebs on CT scans one week after operation, and the rate of significantly shrunken target subpleural blebs and wall thickness, as well as the incidence of postoperative complications, including fever, chest pain, pleural effusion, hemorrhage, and infection after operation were observed and compared between the two groups. Results: The air leakage discontinuance rate in APC+ group was significantly higher than that in APC group 24 hours after operation (90.0% vs 52.4%, P<0.05), and the rate in APC+ group was also significantly higher than that in APC group one week after operation (96.7% vs 66.8%, P<0.05). There was no significant difference in the disappearance rate of target subpleural blebs on CT scans one week after operation and the incidence of significantly shrunken target subpleural blebs and wall thickness (both P>0.05). There was no significant difference in the incidence of postoperative complications such as fever, chest pain and pleural effusion (all P>0.05). Conclusion: The treatment of spontaneous pneumothorax with subpleural blebs by APC plus medical adhesive is safe and effective.

The great debate flashes: surgery versus stereotactic body radiotherapy as the primary treatment of early-stage lung cancer.

Stereotactic body radiotherapy is gaining favour as an alternative therapeutic modality to surgery for patients with early-stage lung cancer. An exponential increase of contributions in the literature has generated a bulk of discordant evidence supporting therapeutic choice for the treatment of fit and medically inoperable patients. This 'Great Debate Flashes' paper aims at producing an up-to-date, concise and user-friendly review of the arguments that surgeons and radiation oncologists bring forward in the discussions with patients and colleagues.

[Effectiveness and safety of argon plasma coagulation via thoracoscopy on the treatment of spontaneous pneumothorax with subpleural bullae].

Objective: To evaluate the effectiveness and safety of argon plasma coagulation (APC) via thoracoscopy on the treatment of spontaneous pneumothorax with subpleural blebs. Methods: Thirty patients with spontaneous pneumothorax with subpleural blebs were retrospectively analyzed during the period of Nov, 2012 to June, 2015 in Rizhao Hospital of Traditional Chinese Medicine. According to the classification of pulmonary bullae through medical thoracoscopy by Reid, type Ⅱand partial type Ⅲ pulmonary bullae (2 cm ≤ diameter <5 cm) were coagulated by argon, and pleural adhesions were mutilated by high frequency electrocision. Two years' follow-up was carried out to observe short-term and long term effect. Results: Thirty-nine pulmonary bullae were found in thirty patients, mainly in the upper lung (28 cases, 71.8%), including 28 type Ⅱ bullae (71.8%), 11 type Ⅲ bullae (28.2%) and most of them were single transparent bullae (24/39, 61.5%). Follow-up of short-term (72 h) effective rate was 70.0% and long-term effective rate was 89.3%. Conclusion: The application of APC via thoracoscopy in the treatment of subpleural bullae is safe and effective.

Hybrid Minimally Invasive Approach for Transvenous Lead Extraction: A Feasible Technique in High-Risk Patients.

INTRODUCTION: Despite the overall safety, transvenous lead extraction (TLE) remains a challenging procedure with inherent risks, where surgery can still be required in elective cases. In this study, we report our experience with a minimally invasive "hybrid" approach, defined as a procedure performed by an electrophysiologist with the support of a cardiac surgeon in the same operative session. METHODS AND RESULTS: We reported 12 cases of planned hybrid lead extraction; minithoracotomy and thoracoscopy were performed on 10 (83%) and 2 (17%) patients, respectively. A total of 25 leads out of 27 (median lead age 19 years) were successfully extracted with laser, mechanical or combined transvenous sheath. In 3 patients, the direct monitoring of vascular and myocardial integrity allowed for prompt treatment of potential vascular injury during the lead extraction maneuvers. Mean in-hospital stay was 4 ± 2 days. There were no major intraoperative complications and no deaths occurred after 30 days' follow-up. CONCLUSION: The hybrid approach, with minithoracotomy or thoracoscopy, is feasible and it might increase the safety in the most challenging TLE procedures: the minimally invasive surgical intervention allows for continuous monitoring of the critical cardiac structures and prompt treatment of potential complications.

Efficacy of Aidi Injection () on overexpression of P-glycoprotein induced by vinorelbine and cisplatin regimen in patients with non-small cell lung cancer.

OBJECTIVE: To investigate the efficacy of Aidi Injection () on overexpression of P-glycoprotein (P-gp) induced by vinorelbine and cisplatin (NP) regimen in patients with non-small cell lung cancer (NSCLC), and study the difference between intravenous administration and targeting intratumor administration of Aidi Injection with thoracoscope. METHODS: Totally 150 patients with NSCLC were randomly assigned to the control group, the intravenous group and the intratumor group by the random envelope method, 50 cases in each group. The patients were treated with NP regimen (2 cycles), NP regimen (2 cycles) plus Aidi intravenous injection, or NP regimen (2 cycles) plus Aidi intratumor injection with thoracoscope, respectively for 6 weeks. The clinical effificacy was observed based on Response Evaluation Criteria in Solid Tumors (RECIST) rules, the expression of P-gp in the tumor tissue was tested before, 3 and 6 weeks after treatment, the safety was evaluated by monitoring the toxicity in the process of treatment, and the progression-free survival (PFS) was measured. RESULTS: Fifteen cases dropped out because of the irreconcilable conditions which had no relationship with the treatment, 4 in the control group, 5 in the intravenous group, and 6 in the intratumor group, respectively. Compared with the control group, the response rates (complete remission + partial response) and the disease control rates (complete remission + partial response + stable disease) were significantly higher, the P-gp expressions were significantly decreased after 3 and 6 weeks of treatment, and the Kaplan-Meier survival curves of PFS were significantly longer in the intravenous and intratumor groups (P<0.05 or P<0.01), and the intratumor group showed better effects than the intravenous group (P<0.05 or P<0.01). Compared with the control group, the occurrences of rash, nausea and leukocytopenia were signifificantly decreased in the intravenous and intratumor groups (P<0.05), but without signifificant difference between the intravenous and intratumor groups (P>0.05). CONCLUSION: Aidi Injection not only improves the effificacy of NP regime, but also has the function of reducing adverse events and preventing against overexpression of P-gp induced by chemotherapy of NP regimen.

Medical Thoracoscopy in Pleural Disease: Experience from a One-Center Study / 결핵및호흡기질환

BACKGROUND: Medical thoracoscopy (MT) is a minimally invasive, endoscopic procedure for exploration of the pleural cavity under conscious sedation and local anesthesia. MT has been performed at the Seoul National University Hospital since February 2014. This paper summarizes the findings and outcomes of MT cases at this hospital. METHODS: Patients who had undergone MT were enrolled in the study. MT was performed by pulmonologists, using both rigid and semi-rigid thoracoscopes. During the procedure, patients were under conscious sedation with fentanyl and midazolam. Medical records were reviewed for clinical data. RESULTS: From February 2014 to January 2016, 50 procedures (47 cases) were performed (diagnostic MT, 26 cases; therapeutic MT, 24 cases). The median age of patients was 66 years (59–73 years), and 38 patients (80.9%) were male. The median procedure duration from initial incision to insertion of the chest tube was 37 minutes. The median doses of fentanyl and midazolam were 50 µg and 5 mg, respectively. All procedures were performed without unexpected events. Of the 26 cases of pleural disease with an unknown cause, 19 were successfully diagnosed using MT. Additionally, diagnostic MT provided clinically useful information in the other six patients. Therapeutic MT was very effective for treatment of malignant pleural effusion or empyema. The median number of days with chest tube drainage was 6 (3 days for diagnostic MT and 8 days for therapeutic MT). CONCLUSION: MT is a useful and necessary procedure for both diagnosis and treatment of pleural diseases.

Spontaneous ventilation anaesthesia: total intravenous anaesthesia with local anaesthesia or thoracic epidural anaesthesia for thoracoscopic bullectomy.

OBJECTIVES: At present, few data exist regarding the comparisons of perioperative outcomes and recurrence of spontaneous ventilation (SV) video-assisted thoracic surgery (VATS) bullectomy using total intravenous anaesthesia (TIVA) with local anaesthesia (LA) or thoracic epidural anaesthesia (TEA). We evaluated the feasibility and safety of TIVA with LA in the management of primary spontaneous pneumothorax (PSP). METHODS: We conducted a single-institution retrospective analysis of patients undergoing VATS bullectomy between July 2011 and May 2015; 240 patients were included for analysis. Preoperative, intraoperative and postoperative variables of patients undergoing VATS bullectomy using TIVA-TEA (n = 140) were compared with those using TIVA-LA (n = 100). RESULTS: Baseline demographics were similar between groups. No patients in either group required conversion to thoracotomy. Three patients (TIVA-TEA: 2; TIVA-LA: 1) required conversion to intubated general anaesthesia. Both groups had comparable surgical duration, estimated blood loss, peak EtCO2 and lowest intraoperative SpO2 level. Postoperatively, thoracic drainage volume, duration of chest tube drainage and hospitalization cost did not differ between groups. The incidence of postoperative complications between groups was not significant (2% for TIVA-TEA vs 2% for TIVA-LA, P = 1.00). Pneumothorax recurrence rate was 3% in TIVA-TEA cases (n = 4) and 2% in TIVA-LA cases (n = 2). CONCLUSIONS: SV-VATS bullectomy using TIVA with LA or TEA is technically feasible and safe. Both groups have comparable short-term outcomes and recurrence rates; TIVA-LA seems a valid alternative to TIVA-TEA for the surgical management of PSP under SV.

Non-intubated uniportal lung surgery†.

Uniportal video-assisted thoracoscopic surgery (uniVATS) is currently being used to diagnose and treat several intrathoracic conditions with minimal morbidity and reduced hospital stay compared with standard multiport VATS surgery. The potential advantages of uniVATS can be also enhanced by the adoption of loco-regional anaesthesiological techniques in non-intubated or awake patients yielding the possibility of performing an ever larger proportion of thoracic surgical procedures in an outpatient setting. This review will look at organizational and technical aspects of implementing a non-intubated uniVATS program.

Surgical Outcomes of Pneumatic Compression Using Carbon Dioxide Gas in Thoracoscopic Diaphragmatic Plication

BACKGROUND: Surgical correction needs to be considered when diaphragm eventration leads to impaired ventilation and respiratory muscle fatigue. Plication to sufficiently tense the diaphragm by VATS is not as easy to achieve as plication by open surgery. We used pneumatic compression with carbon dioxide (CO2) gas in thoracoscopic diaphragmatic plication and evaluated feasibility and efficacy. METHODS: Eleven patients underwent thoracoscopic diaphragmatic plication between January 2008 and December 2013 in Pusan National University Hospital. Medical records were retrospectively reviewed, and compared between the group using CO₂ gas and group without using CO2 gas, for operative time, plication technique, duration of hospital stay, postoperative chest tube drainage, pulmonary spirometry, dyspnea score pre- and postoperation, and postoperative recurrence. RESULTS: The improvement of forced expiratory volume at 1 second in the group using CO₂ gas and the group not using CO₂ gas was 22.46±11.27 and 21.08±5.39 (p=0.84). The improvement of forced vital capacity 3 months after surgery was 16.74±10.18 (with CO₂) and 15.6±0.89 (without CO₂) (p=0.03). During follow-up (17±17 months), there was no dehiscence in plication site and relapse. No complications or hospital mortalities occurred. CONCLUSION: Thoracoscopic plication under single lung ventilation using CO₂ insufflation could be an effective, safe option to flatten the diaphragm.

Thoracoscopic versus open repair of tracheoesophageal fistulas and rates of vocal cord paresis.

BACKGROUND/PURPOSE: The purpose of this study was to investigate the rates of vocal cord paresis/paralysis (VCP) in patients treated for esophageal atresia (EA) with and without fistula performed thoracoscopically versus open. METHODS: A retrospective review of EA cases performed from 2008 to 2014 in an integrated health care system was performed. RESULTS: A total of 31 cases of EA were performed by 6 surgeons at 4 different institutions. Seventeen cases were performed thoracoscopically, whereas 14 cases were performed open. In the thoracoscopic group, the average gestational age (weeks) of the patient was significantly higher 38.3 vs. 35.2 (p=0.016) as well as the average birth weight (grams) 2843 vs. 2079 (p=0.005). There was no difference in the postoperative length of stay, rates of anastomotic stricture, leak, or tracheomalacia. There were 10 cases of vocal cord paresis, 9 from the thoracoscopic group and one from the open group (p=0.007). Of the 10 cases of VCP, 6 were unilateral (left sided) and 4 were bilateral. Of the 10 cases, 6 resolved, 2 resulted in permanent paralysis, and 2 are currently still being evaluated. CONCLUSIONS: Thoracoscopic repair of EA appears to have higher rates of VCP. The results are thought to be from thoracoscopic dissection of the esophagus high into the thoracic inlet.